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Facial bone loss and premature aging

PSYCHOLOGIC, ESTHETIC AND FUNCTIONAL CONSEQUENCES OF TOOTH LOSS

A COMPREHENSIVE REPORT BY JAMES J. KHAZIAN DMD. AFAAID

FACIAL BONE LOSS AND PREMATURE AGING

CAN LOSING TEETH MAKE YOU LOOK OLDER?

Hi, my name is Dr. James J. Khazian. I am excited and happy to provide this valuable report to my patients and the general public. The very important issue of facial bone loss following tooth extraction has been grossly neglected in dentistry. The devastating consequences of this kind of bone loss are multifaceted and complex, and severely affect many aspects of an individual’s life.

This report is designed to motivate awareness by dentists and the general public equally about the effects of tooth loss, the resulting bone loss in the jaw, and consequential facial collapse and premature aging. This has historically been grossly ignored by professionals in the field, due to a lack of knowledge about the relationship between tooth and bone volume and how volume is decreased after tooth loss.

Replacement of missing teeth in traditional dentistry focused on restoring the lost tooth with dentures and bridges to provide chewing function. This approach however did not address the bone condition and prevent future bone loss. Now dentists and patients have another option. Dental implants are considered a permanent replacement of tooth loss. It works, looks, and acts like a natural tooth. But before we go any further, we need to understand why loosing bone is bad.

To answer this very important question, let’s discuss the importance of the jawbone and the whole skeletal system. As every one knows our skeletal system is the framework for our body, it holds all of our organs together. Muscles and skin drape over this framework and any change in this framework directly reflects through skin. Athletes are not able to create beautiful muscles and shape if they do not have a sufficiently strong skeletal and bone structure. Strong and well-shaped muscles simply would not have a framework to hold on to.

WHAT IS THE RELATIONSHIP BETWEEN TEETH AND THE SUPPORTING FACIAL BONE?

Development of the jawbone starts in the fetus stage and is primarily initiated by presence and development of tooth buds, which develop into baby and adult teeth. The jawbone does not develop in the absence of baby or adult teeth. This close relationship between teeth and facial bone continues throughout life. The maintenance of the volume and density of facial bone is highly dependant upon teeth and the stimulating forces transmitted to the bone through functioning teeth. Every time these forces are modified, a definite change occurs in the internal architecture and external configuration. Bones need proper chewing forces to maintain their form and density. Teeth transmit compressive and tensile forces to the surrounding bone. When a tooth is lost, the lack of stimulation to its supporting bone causes a decrease in bone volume and density. According to credible research, 25% of bone loss occurs during the first year after tooth loss and continues into the years to come.

A tooth is necessary for the development of facial bone, and stimulation of this bone by chewing forces is vital for maintenance of its volume and density. This issue, of utmost importance, has been ignored in the past and is currently being ignored by traditional dentistry. Dentists most often overlook facial bone loss that occurs after tooth extraction. The general public is often not educated about the anatomic, the potential esthetic, and functional consequences of continued bone loss. The bone loss often accelerates when the patient wears a removable denture. Yet patients do not understand that the bone loss occurs over time, and at a greater rate with removable dentures.

Traditional dentistry has emphasized preventive measures to decrease tooth loss. But unfortunately it has not addressed the issue of bone loss after tooth extraction. Tooth loss causes remodeling and shrinkage (resorption) of the supporting jawbone and eventually leads to atrophic facial bone and collapse of overlying muscle and skin. Although the patient is often not aware or informed of potential consequences, over time they will occur. Today, this issue should be prioritized and dentists must take it upon themselves to educate the public about the serious functional, psychological, and aesthetic consequences of bone loss.

FUNCTIONAL CONSEQUENCES

Continued loss of facial bone, especially in multiple extractions, compromises the ability of upper and lower arches to support dentures. In advanced phases of bone loss, certain nerves that are otherwise enclosed and protected by the bone are exposed and only protected by the gum tissue. This condition makes the use of dentures extremely painful since the pressure of the dentures is placed directly onto these exposed nerves. As a result, acute pain and/or transient to permanent numbness (paresthesia) could occur. If the denture is supported by a few remaining natural teeth (partial dentures), lack of support from atrophied bone will cause excessive load and force on those teeth. This will result in shifting and eventual loss of additional teeth, which in turn will lead to even more bone loss. Because these consequences are not sudden and occur gradually over a period of years, patients often learn to tolerate and adapt.

The difference in chewing forces in a person with natural teeth and one who wears dentures is dramatic. In the molar region of a person with natural teeth, the average force has been measured at 150-250 psi. Certain patients who grind or clench their teeth may exert a force of up to 1000 psi. The maximum force in denture patient is reduced to less than 50 psi. The longer an individual wears dentures, the less force they are able to generate. Individuals wearing dentures for more than 15 years may have a maximum chewing force of 5.6 psi.

As a result of this decreased force and instability of dentures, chewing efficiency is severely compromised. Many patients with dentures will avoid most hard food, some are only able to eat soft or mashed food, and some claim they eat more efficiently without their dentures. Lower intake of fruits, vegetables, and vitamin A in these individuals leads to digestive and other systemic disorders. As a result, these individuals take more drugs/supplements compared to those with natural teeth and better chewing ability.

Also, the reduced consumption of high fiber foods could induce digestive problems in denture wearing individuals with deficient chewing performance. Credible research and reports provide proof suggesting that a compromised dental function causes poor chewing and swallowing ability and digestive disorders, which in turn may favor systemic changes favoring illness, debilitation, and shortened life expectancy.

Several reports correlate individuals’ health and life spans to their dental health. These reports point to significant relationship between dental disease and cardiovascular disease, the latter being a major cause of death today. It is therefore easy to believe that restoring the dental function of these individuals to a more normal function may indeed enhance the quality and length of their lives.

Several studies concluded that the use of partial dentures deteriorates the health of the gums and remaining natural teeth. Individuals wearing partial dentures often exhibit loosening of the retaining natural teeth, heavier plaque retention, increased gingivitis and gum bleeding, more tooth decay, and accelerated bone loss. Dentists and patients should study all these issues of tooth and bone loss more carefully and look at other available options for a long-term solution rather than a quick fix.

Dental implants should be seriously considered as the first option at the time of tooth extraction. Dentists should discuss the benefits of implants with their patients and inform them about the consequences of not having dental implants.

PSYCHOLOGICAL CONSEQUENCES

The psychological effects of tooth and bone loss are complex and varied, and range from minimal to a state of neuroticism. Most denture wearers feel their social life is significantly affected. They are concerned about kissing and romantic situations, especially if the partner is unaware of their oral handicap. Surveys indicate that not all patients are able to use their dentures. Some individuals are even reluctant to use their dentures for social occasions. Individuals with severe bone loss are not able to use their dentures at all. They rarely leave their home environment and when they feel forced to venture out, the thought of meeting and talking to people when not wearing their teeth is unsettling.

Majority of denture wearers complain of some speech difficulties, some having severe speech problems. It is easy to understand how this will affect an individual’s social activities. Awareness of movement of dentures, especially the lower one, severely affects the emotional and psychological state of individual. These people often avoid eating in public. Even at home, most denture wearers limit their diet to soft food and avoid fruits and vegetables.

The use of denture adhesives is a clear indication of the instability of dentures, especially during advanced bone loss. The annual sale of denture adhesives in the U.S. is in the hundreds of millions of dollars. The patient is willing to accept the unpleasant taste, need for recurrent application, inconsistent denture fit, and continued expense for the sole benefit of increased retention of the denture.

It is not difficult to imagine the psychological impact of dentures on an individual’s self image. It can gradually change an individual’s behavior from an outgoing social person to one who prefers solitude, who is constantly aware of her/his dentures, and one who avoids any social situations.

Such dental problems can be avoided or corrected if dentists and/or patients look beyond a quick replacement of one or several missing teeth. Rather, plan a sound treatment option that prevents bone loss and the debilitating consequences. With advances in the field of implant dentistry, such solutions are very well within reach of any one who has lost teeth or is about to.

Patients treated with dental implants have shown significant improvement in psychological health compared with their previous state wearing traditional, removable dentures, and perceive the implant supported teeth as an integral part of their body. Clearly the lack of retention and psychological risk of embarrassment in the denture wearer with removable denture is a concern the dental profession must address.

ESTHETIC CONSEQUENCES

A well-shaped, symmetrical face with healthy looking facial skin needs an intact and healthy underlying bone structure. This is demonstrated well in young adults with intact boney structures. The same is observed in middle aged or even old individuals who have been able to maintain their facial structure. It might be called graceful aging but it is not an accidental phenomenon or due to luck. It is directly related to the state of their oral and dental health. A 65-year-old individual who has been able to maintain all his or her teeth looks much younger than the same age individual who has lost teeth and wears dentures.

The facial changes that naturally occur in relation to the aging process can be accelerated by the loss of teeth and the resulting facial bone loss. A decrease in facial height from a collapsed vertical dimension (distance between tip of the nose and chin) causes several facial changes. The immediate and most prominent change is creation of wrinkles around the mouth. Of equal importance is the thinning of lips. Upper and lower lips loose their fullness. As the vertical dimension progressively decreases, the chin will move forward and create a prognathic facial appearance.

These conditions result in a decreased upward curvature of lips (seen more prominently in a smiling face) and dropping of the corners of the mouth, giving the patient an unhappy facial appearance when the mouth is at rest. The thinning of the lips from lost vertical dimension, underlying bone loss, and loss of tonicity of the muscles involved in facial expression is more pronounced in women. They often use one of two techniques to hide this cosmetically undesirable appearance: either no lipstick or minimum make-up, so that little attention is brought to this area of face or application of lipstick over the vermilion border to give the appearance of fuller lip. Collapse of upper lip due to underlying bone loss and loss of fullness will make the nose appear larger than if the upper lip had more support.

Even though facial muscle tone decreases as we age, this process is accelerated in patients with tooth and bone loss. This loss of tonicity causes lengthening of the lips. Since facial muscles are attached to facial bone, the bone loss severely affects these muscles and their function. The facial skin begins to sag. The combination of a prognathic chin, sagging muscles and skin, long lips, and a large looking nose makes the individual appear prematurely aged.

Since these changes occur gradually, patients are unaware that these changes are from the loss of teeth. Therefore it is the dentist’s responsibility to explain these consequences to patients before extracting teeth and providing all other options at this time. The best time to plan and do implant placement is at the time of extraction and not after. The amount of bone loss in the early months after extraction, will make implant placement much more complicated. It is strongly recommended to plan tooth extractions very carefully and seriously consider the resulting bone loss from tooth extraction and dire esthetic, functional, and psychological consequences.

ADVANTAGES OF DENTAL IMPLANTS

The use of dental implants to replaces missing teeth or as a support for dentures offers a multitude of advantages.

The primary reason to consider dental implants to replace missing teeth is the maintenance of valuable facial bone. The dental implant placed into the bone serves not only as an anchor for the new teeth or to stabilize dentures, but it also serves as one of the best preventive procedures in dentistry. The chewing forces are transmitted to the bone surrounding the dental implant that stimulate bone growth and maintain density and volume. Implants should be placed at the time of extraction to immediately stop bone loss. Delaying implant placement, after extraction, will only cause significant bone loss and eventual complications resulting in the need for bone graft. Research has concluded that most bone loss occurs in the first year following extractions.

Today, replacing a tooth with dentures or bridges is no longer the best option or even an acceptable one. Dental problems associated with these kinds of restorations are not few.

Bridges are anchored to adjacent natural teeth (abutment teeth), and in the process of making them they are drilled to almost half their size. This will obviously weaken them. Often abutment teeth become sensitive and might require root canal treatment. Bridges fail due to weakness and decay of the abutment teeth, which leads to more tooth loss. Therefore we can only consider bridges as a temporary solution for tooth loss.

Dentures are even worse. These removable restorations are bulky, uncomfortable, catch food particles, interfere with speech, are often painful, etc. Both dentures and bridges cause facial bone loss, which is the primary cause of facial collapse and premature aging.

In today’s modern dentistry, the best acceptable solution for tooth loss is dental implant. From the replacement of single missing tooth to extensive reconstruction and replacement of several or even all teeth, dental implants offer the healthiest and most intelligent solution.

Some of the advantages of dental implants include:

Maintenance of facial bone. As previously discussed, dental implants prevent bone loss. This is due to stimulation of the jawbone by the chewing forces transmitted by inserted implants.
Improved chewing ability. Dental implants provide a solid and stable foundation for new teeth. Patients are able to eat without worrying about moving or loose dentures.
Improved phonetics. Eliminating bulky, loose dentures, improves phonetics significantly. Dental implants feel like natural teeth and patients actually forget they have missing teeth.
Improved psychological health. Having dental implants is like having a new set of natural teeth. With all the comfort of eating, talking, and socializing without the fear of embarrassment, the individual’s self image is tremendously enhanced.
Improved esthetics. By preventing bone loss, often through bone repair and replacement, implant procedures significantly improve facial esthetics.
Regained chewing awareness. Chewing forces are directly transmitted to the jawbone, which helps patient’s chewing awareness. With dentures, the roof of the mouth (palate) and all gum surfaces are covered, which prevents taste and chewing reception.
Maintenance of muscles of chewing and facial expression. A sound, healthy bone structure is vital for intact overlying facial muscles. By preventing facial bone loss, dental implants maintain the integrity of facial muscles.
Increased retention and stability of dentures. Loose, instable dentures can effectively be anchored to jawbone and provide stability and retention.

These are the main, but not the only, advantages of dental implants.

The goal of modern dentistry is to return patients to a level of oral health that they are accustomed to. Patients who lose teeth and use fixed or removable dentures may be unable to recover normal function, esthetics, comfort, or speech with these traditional restorations.

However, an implant restoration can return the function to near normal. An implant stimulates the bone and maintains its dimensions in a manner similar to healthy natural teeth. As a result, the facial features are not compromised by lack of support. In addition, implant supported restorations are positioned in relation to esthetics, function, and speech to mimic natural teeth. Because implant teeth are not bulky and take only as much space in the mouth as natural teeth do, facial muscles and tongue do not undergo changes.

In the past 15 years implant dentistry has evolved into a predictable treatment model for replacement of missing teeth. Advantages of implants over traditional dentures and bridges make them the best choice for this purpose. Fortunately, the awareness in the general public about dental implants and their advantages has increased significantly. This has motivated many dentists to become more knowledgeable and offer this treatment to their patients. This is very promising and will undoubtedly improve the oral health in the U.S.

Our office provides the most comprehensive implant services. Both surgical and restorative phases of your treatment are done by Dr. Khazian. For you, this means a more consistent treatment process and less confusion. There will be no referrals back and fourth to other offices and doctors. This means a smooth and fast treatment process and better results. We offer the following:

Single tooth replacement: Quite often this is done using a flapless procedure and immediate loading. This means, no stitches are placed and a tooth is placed on the implant right after surgery. Flapless procedure ensures the most esthetic result and creates gum tissue around the implant that resembles that of natural teeth.

Multiple teeth replacement: The goal of modern dentistry is to restore patients to normal esthetic, comfort, function, speech, and health. However, the more teeth a patient is missing, the more challenging this goal becomes with traditional dentistry and the use of dentures and bridges. By using advanced implant designs, materials, and techniques, predictable success is now a reality for the treatment of many challenging clinical situations.

Replacement of all teeth: We provided this amazing service to our patients. If you have lost all your upper or lower teeth or even both, it is possible to effectively replace them with dental implants. Patients who have had this service, did not have to use dentures any more, and felt a sense of freedom, joy, and improved self-esteem. They noted, eating, speaking, and socializing was more enjoyable.

Bone Grafts and Reconstruction: If you have suffered bone loss and need bone grafting in preparation of implant placement, we offer the cutting edge techniques, materials, and 16 years of advanced education and experience. You will receive these treatments in the most comfortable setting and will see only the best results.

Denture stabilization, using implants: If you have dentures that are loose and unstable, hurt your gum and do not chew your food properly, implants can help. Dentures can be anchored to implants to provide better stability. With new techniques this can be achieved in a short, one-hour visit, with minimal flapless surgery.

Whether you have one, two, or more teeth missing, have suffered bone loss or have denture problems, call or visit our offices. We will help you learn more about all your options.

SAN DIEGO OFFICE

3969 Fourth Avenue, Suite 205
San Diego CA. 92103
Telephone: (866)4my-smile

ESCONDIDO OFFICE

727 East Grand Avenue
Escondido CA. 92025
Telephone: (760)738-7000

ABOUT DR. KHAZIAN

During the past 16 years, Dr. Khazian has been striving to offer the best of dentistry to his patients. In order to be on the cutting edge of dentistry, he has attended numerous hours of advanced education in all aspects of dentistry, including surgical and restorative implant dentistry, cosmetic dentistry, neuromuscular dentistry and TMJ, orthodontics and principles of full mouth reconstruction. Being knowledgeable and adept in all these aspects enable Dr. Khazian to treat the most complicated dental problems, often times helping patients who have been turned away by other dentists.

Because of the experience and skill he has demonstrated in surgical and restorative implant dentistry, Dr. Khazian was awarded “Associate Fellow of the American Academy of Implant Dentistry,” a distinction awarded to less than 1% of all dentists. He has been surgically placing and restoring dental implants for the past 15 years and has extensive experience in single tooth, multiple teeth or full mouth implant reconstruction, with special attention to esthetic considerations. He has been performing immediate load implants with a success rate of 99%. Implants placed and restored by Dr. Khazian in the esthetic zone (upper and lower front of mouth) are practically indistinguishable from natural teeth. He has been performing and mastering flapless procedures that require no stitches. He offers sedation or general anesthesia for patients who prefer to have those services. He provides implant services to his patients in the most comfortable manner, in a modern, high-tech office. Because of his strict sterilization protocols and adhering to the most advanced and innovative surgical techniques, almost all procedures are done with minor or no post-operative discomfort.

Dr. Khazian has been providing his patients with the most advanced cosmetic dental care since 1990. His cosmetic work has been recognized as the best by the American Academy of Cosmetic Dentistry and featured on the cover of it’s Journal. His smile creations are beautiful, healthy, and above all, natural looking.

He has appeared in several TV programs as guest speaker including MDTV medical news and Heartbeat of America.

He has offered this exceptional, comprehensive dental care to over 10,000 patients.

Because he strongly believes in organized dentistry and exchange of knowledge and technology, he is actively participating and is a member of the following distinguished dental organizations:

American Academy of Implant Dentistry
American Academy of Cosmetic Dentistry
International Congress of Oral Implantology
American Dental Association
California Dental Association

TELEPHONE: SAN DIEGO (866)4my-smile ESCONDIDO (760)738-7000

Japanese scientists grow teeth from single cells

Washington (Reuters). Japanese researchers have announced recently they had grown normal looking teeth from single cells in lab dishes, and transplanted them into mice.They used primitive cells, not quite as early as stem cells, and injected them into a framework of collagen, the material that holds the body together.After growing them, they found their structures had matured into components that make teeth, including dentin, enamel, dental pulp, blood vessels, and periodontal ligaments.

They were arranged appropraitely when compared with a natural tooth, researchers reported in the journal Nature Methods.

The teeth grew and developed normally when transplanted into a mouse, said Takashi Tsuji of the Tokyo University of Science in Chiba, Japan and colleagues.

They said their method was the first to show an entire organ could be replaced using just a few cells. “To restore the partial loss of organ function, stem cell transplantation therapies have been developed” they wrote.

The ultimate goal of regenerative therapy, however, is to develop fully functioning bioengineered organs that can replace lost or damaged organs after disease, injury or aging.

The researchers went after the “organ germ”, the early cells made using partially differentiated cells known as epithelial and mesenchymal cells. In this case the cells were taken from what is known as the tooth germ, the little bud that appears before an animal grows a tooth.

“Our reconstituted tooth germ generates a complete and entirely bioengineered tooth”, they wrote. “This study thus provides the first evidence of a successful reconstitution of an entire organ via the transplantation of bioengineered material”, they added.

This finding should encourage the future development of organ replacement by regenerative therapy.

Dental implants in adolescents

The World Health Organization defines an adolescent as being between the ages of 10 and 19. The jaw bone undergoes dynamic growth activity during these years. Placing dental implant in such an environment can lead to unpredictable results. A major concern in placing dental implants in adolescents is the possibility of relocation or displacement with time with respect to natural dentition. In addition, the placement of a rigid implant-born prosthesis may inhibit growth activity.Researchers suggest that maxilla changes in all 3 planes of space. It is difficult to predict the behavior of implants in this dynamic situation. To prevent complications and enhance predictability, it is best to wait until cessation of growth before dental implant placement in a young person. Girls grow actively until 14-15 years of age; boys, on the other hand, typically stop growth at age 17-18 years. the most ideal method to assess growth status is not chronological or even dental age but comparison of a skeletal film over time (hand-wrist or lateral cephalometric).Particular developmental disorders may necessitate the use of dental implants in still-growing adolescents. For instance, hypohidrotic ectodermal dysplasia cause hypodontia. Generally speaking, it is prudent to wait until the completion of skeletal maturation before dental implant placement to avoid imperfect fixture postioning or stunt osseous expansion.

Postoperative instructions following dental implants

Placement of dental implants usually does not create a great deal of pain. However, carefully reading and following these instructions will ensure smooth and easy healing. Please read the following instructions before surgery. If you have any questions or concerns, discuss those with Dr. Khazian or his surgical assistants.If you have extreme pain and/or swelling which can not be controlled with your prescribed medications, please call our office immediately. After hours, you may reach Dr. Khazian at his cell phone at 858-775-5545.LIMIT PHYSICAL ACTIVITY during the first 3 days after surgery. Over exertion may lead to postoperative bleeding and discomfort.

AVOID SMOKING COMPLETELY, as it tends to delay healing and interfere with regeneration.

Take any regularly scheduled medication (for diabetes, high blood pressure, etc.) on your regular schedule unless advised to do otherwise. You may also continue taking your multivitamins and other nutritional supplements.

If sutures have been placed following implant surgery, they will be removed 2 weeks after surgery, at the time of your post-operative check-up. Some sutures may become loose and fall out prematurely. This will not pose any problem and may be ignored.

EATING

Nutritious diet during the healing period is very important. You may start eating as soon as numbness wears off and bleeding stops. Your first meal can ideally be a frozen protein shake containing banana, apple, creamy peanut butter, and milk. Avoid including strawberry, kiwi and such seeded fruits as their seeds may trap in the wound and cause infection. A few hours after bleeding stops, begin drinking a lot of water and non-citrus juices. DO NOT USE STRAW. It may dislodge the blood clot and delay healing. Avoid drinking carbonated beverages completely for several weeks. The day following surgery, start a soft nutritious diet rich in protein. This may include scrambled eggs, well cooked chicken soup, cottage cheese, milk, plain yogurt, well cooked and mashed vegetables, banana, and fruit shakes. Hot foods and drinks should be avoided. Avoid foods and/or fruits which contain seeds, nuts, or kernels such as popcorn, peanuts, strawberry, and kiwi, or are hard or crunchy. Remember, eating can prevent nausea sometimes associated with certain medications.

YOUR MEDICATION

Your prescribed medications play an extremely important role in your healing. The purpose of these medications is to prevent infection and swelling and control pain. Please follow directions carefully and take them exactly as directed. This will ensure a smooth healing and minimum pain. It is extremely important to complete the course, regardless of pain and/or swelling. Do not assume the medication to be unnecessary if you do not have pain or swelling. Yogurt with active cultures or acidophilus should be taken while on antibiotics to prevent diarrhea. If you are given antibiotics and take birth control pills, you should be aware that the birth control may become ineffective, therefore take appropriate precautions. Please do not drink alcoholic beverages while taking prescription medication.

Oral Hygiene

Good oral hygiene is essential to good healing. Do not rinse your mouth for at least 12 hours after surgery, as rinsing interferes with blood clotting and proper wound closure and healing. After 12 hours, start very gentle rinsing with warm salt water (1/2 teaspoon of salt in a cup of warm water). Do this at least 4- times a day, especially after meals. Proceed with your regular brushing and flossing after 12 hours, but stay away from the surgical site. Remember, surgical site should be left completely undisturbed during the first 2 weeks following surgery. Do not brush teeth immediately adjacent to surgical site for several days. Allowing the tissues to rest undisturbed assists the healing process. Avoid vigorous chewing, excessive spitting, or aggressive rinsing. If you routinely use a Water Pik, avoid doing so during the healing phase. Initial healing may be delayed, active bleeding restarted, or infection introduced. After 2 weeks you may gently brush the surgical site. If there are healing abutments placed on your implants which emerge through your gum, you should brush them routinely and keep them clean and free of plaque.

BRUISING

Discoloration of the facial skin adjacent to the surgical site rarely occurs because of age, medications (aspirin, motrin, anticoagulants), and skin complexion. While cosmetically undesirable, this skin discoloration is harmless and will resolve over the next several days on its own without any medical intervention.

LIMITED OPENING

Any stiffness in the jaw muscles can be relieved by applying a warm moist towel to the affected side of the face. Chewing gum at intervals may also help relax the muscles.

FEVER

There may be a slight elevation of temperature for the first 24 to 48 hours after surgery. If fever is present, it is extremely important to drink plenty of fluids. For fevers which exceed 101 degrees, please call the doctor especially if this fever is associated with limited opening. It is also appropriate to make sure that prescribed antibiotics are being taken correctly.

BLEEDING

Expect minor bleeding or oozing. If bleeding persists, it is best controlled by biting on gauze packs. These packs are best changed every 45 minutes until bleeding subsides. Keeping your head elevated and sitting upright help stop bleeding. The most frequent cause of bleeding post-operatively is spitting or rinsing following surgery. PLEASE DO NOT RINSE OR SPIT FOR THE FIRST 12 HOURS FOLLOWING SURGERY. When you lie down keep your head elevated on a pillow. You may wish to place a towel on your pillowcase to avoid staining from any blood tainted saliva.

SWELLING

You have been given an anti-inflammatory medication (Motrin) to prevent and control the post-operative swelling. Start taking this medication immediately following surgery. Swelling may also be controlled by the immediate application of ice packs for the first 36 hours following surgery. Ice packs should be applied to the outside of the face in intervals of 30 minutes on and 15 minutes off.

DRIVING AND ACTIVITIES

While under the influence of any anesthetic agent or narcotic pain medication, it is advised that you not drive a car, operate machinery, climb ladders, or make any important financial decisions. It is also advised that you refrain from any strenuous activity, as this may lead to an increase in swelling as well as the potential for injury because of impaired coordination caused by narcotic medications. Whenever possible, we encourage patients to use non-steroidal anti-inflammatory medications such as Advil, Motrin, or Aleve.

Dental implant treatment considerations for patients taking Bisphosphonates

Bisphosphonates (both oral and intravenous) are used to manage osteoporosis as well as certain types of cancers. These compounds are potent inhibitors of osteoclastic-mediated bone resorption. Therefore, physiologic bone resorption and remodeling are severely compromised in patients receiving bisphosphonate therapy. Additionally, bisphosphonates have antiangiogenic properties and may be directly tumoricidal, making them an important agent in cancer therapy. All bisphosphonate compounds accumulate over extended periods of time in mineralized bone matrix. Depending on the duration of the treatment and the specific bisphosphonate prescribed, the drug may remain in the body for years.

The efficacy of these agents in reducing bone pain, hypercalcemia, and skeletal complications has been extensively documented in patients with metastatic breast cancer and multiple myeloma, and other tumors that metastasize to bone. Bisphosphonates are also widely used for the treatment of postmenopausal osteoporosis and glucocorticoid-induced osteoporosis. Bisphosphonates can increase bone mineral density resulting in a decreased incidence of skeletal complications associated with osteoporosis.

There are a variety of bisphosphonates approved for clinical use in the United States (Table below). The potent intravenous bisphosphonates, pamidronate (Aredia; Novartis Pharmaceutical corp) are typically administered monthly in patients with metastatic bone disease. Except for ibandronate (Boniva; Hoffmann-LaRoche), all of the other bisphosphonates approved for the treatment of osteoporosis are used orally on a daily or weekly schedule.

BISPHOSPHONATE PREPARARTIONS CURRENTLY AVAILABLE IN THE USA

	Primary Indication	Dose	Route	Relative Potency
Etidronate (Didronel)	Paget’s Disease	300-750 mg/daily for 6 months	Oral	1
Tiludronate (Skelid)	Paget’s Disease	400 mg/daily for 3 months	Oral	50
Alendronate (Fosamax)	Osteoporosis	10 mg/day 70 mg/week	Oral	1000
Risedronate (Actonel)	Osteoporosis	5 mg/day 35 mg/week	Oral	1000
Ibandronate (Boniva)	Osteoporosis	2.5 mg/day 150 mg/month	Oral	1000
Pamidronate (Aredia)	Bone Metastases	90 mg/3 weeks	IV	1000 – 5000
Zoldronate (Zometa)	Bone Metastases	4 mg/3 weeks	IV	10000

BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW (ONJ)

In recent years, rare cases of osteonecrosis of the jaw (ONJ) have been reported with the use of bisphosphonates. ONJ is a condition in which the jaw bone spontaneously undergoes necrosis. Possible ONJ symptoms may include: irregular sores with exposed jaw bone, infection (possibly purulent), pain or swelling in the infected jaw, and altered sensation such as numbness or heavy feeling in the jaw.

Patients receiving treatment with these medications have been found to be at risk of experiencing delayed healing and spontaneous soft tissue breakdown leading to intraoral bone exposure after extraction, dental implant surgery, and other oral surgical procedures. The appearance of bisphosphonate associated osteonecrosis is identical to the appearance of osteoradionecrosis in patients who develop it after undergoing head and neck irradiation.

Bisphosphonates are used to treat osteoporosis, paget’s disease of bone and hypercalcemia of malignancy. In patients with osteoporosis, it is expected that bisphosphonates will arrest bone loss and increase bone density, decreasing the risk of pathologic fracture resulting from progressive bone loss. Bisphosphonates are given to patients with cancer to help control bone loss resulting from metastatic skeletal lesions. They reduce skeletal related events associated with multiple myeloma (such as fractures) and metastatic solid tumors (such as breast, lung and prostate cancers) in the bone. The physician’s decision regarding which type of bisphosphonate to use depends on the type of medical condition being treated and the potency of the drug required. For example, orally administered bisphosphonates are often used in patients with osteoporosis, while the injectable bisphosphonates are used in patients with cancer who develop primary lesions of bone or skeletal metastasis.

Bone remodeling is a physiologic function that occurs in normal bone. It removes microdamage and replaces damaged bone with new bone (very similar to what happens when old skin is replaced by new skin). This function takes place within small compartments in the bone. These units are composed of osteoblasts (bone-producing cells) and osteoclasts (bone-resorbing cells). Bisphosphonates bind to bone and incorporate in the osseous matrix. During bone remodeling, the drug is taken up by osteoclasts and internalized in the cell body, where it inhibits osteoclastic function, inhibiting bone resorption. As a result, bone remodeling and turnover becomes profoundly suppressed and, over time, the bone show little physiologic remodeling. The bone becomes brittle and unable to repair physiologic microfractures that occur in the human skeleton with daily activity. In the oral cavity, the jaw bone is subject to constant stress from chewing forces. Thus, it is expected that physiologic microdamage and microfractures occur daily in the jaw. It is theorized that in a patient taking a bisphosphonate, the resulting microdamage is not repaired, setting the stage for oral osteonecrosis to occur.

To explain this in summary, bisphosphonates, alone or in association with a jaw surgery such as dental implant placement or tooth extraction, may lead to bone necrosis. Sequence of events would include the decrease in bone resorption, leading to decreased bone remodeling which may cause necrosis of the bone.

The need for repair and remodeling is increased greatly when patient undergoes jaw surgery such as tooth extraction or dental implant placement. In rare cases when patient is using bisphosphonates, the bone is unable to meet these increased needs, which results in bone necrosis (osteonecrosis).

Patients receiving bisphosphonates intravenously clearly are more susceptible to this kind of osteonecrosis than are those receiving the drug orally. Other factors making the patient more susceptible to osteonecrosis of the jaw (ONJ) include systemic conditions such as presence of diabetes mellitus, overall tumor burden and stage of disease, extent of skeletal involvement, the patient’s overall systemic health, the degree of immunosuppression, the patient’s history of stem cell transplantation, and the patient’s current and historical use of other medications such as chemotherapeutic agents or corticosteroids. Others demonstrating more susceptibility to ONJ are patients with multiple myeloma who are treated with other antiangiogenic agents such as thalidomide, glucocorticoids and bortezomib. Local comorbid factors include oral health status, presence of infection, history of radiation therapy and the presence of myeloma or metastatic cancer at the necrosis site.

CLINICAL SIGN AND SYMPTOMS OF BISPHOSPHONATE ASSOCIATED OSTEONECROSIS OF THE JAW (ONJ)

Recently, cases of ONJ have been reported in the medical and dental literature describing patients with various types of cancer receiving intravenous bisphosphonates to control and treat metastatic bone disease. The patients used pamidronate and zoledronic acid. Additionally, similar cases have been reported in patients taking oral doses of aledronate to treat osteoporosis. The use of bisphosphonates seemed to be the only common link in all cases reported.

The most common clinical history associated with these cases is absence or delayed healing of hard/soft tissue after extractions or dental implant placement. Trauma induced by dentures has also been implicated in the initiation of this pathological condition. In the early stages of ONJ, no radiographic manifestations can be seen. Patients are usually asymptomatic but may develop severe pain because of the necrotic bone becoming infected secondarily after it is exposed to the oral environment. The osteonecrosis often is progressive and may lead to extensive areas of bony exposure. When tissues are acutely infected, patients may complain of severe pain and lack of sensory sensation (paresthesia).

TREATMENT MANAGEMENT RECOMMENDATIONS

Although several cases of osteonecrosis of the jaw (ONJ) have been reported, there have been no documented uniform treatment strategies that would result in a consistent healing of ONJ. In fact, many cases had poor outcomes in spite of therapy, progressing to extensive exposure of bony structures. Treatment strategies include local surgical debridement, bone curettage, local irrigation with antibiotics and hyperbaric oxygen therapy. However none of these therapeutic modalities has been successful. Therefore in patients who are receiving or have received bisphosphonates for the management of cancer or to treat or prevent osteoporosis, prevention of this condition is of paramount importance.

Preventive measures: ONJ is a newly documented oral complication, and consistently effective therapeutic measures have not been identified. Several treatment protocols have been attempted to treat ONJ. Treatment methods included minor debridement under local anesthesia, major surgical sequestrectomies, marginal and mandibular resections, partial and complete maxillectomies and hyperbaric oxygen therapy. Despite the presence of vascularized bone at the surgical margin, no healing has been reported. For this reason, preventive measures are of paramount importance.

A dentist should see the patients before intravenous or oral bisphosphonate therapy begins. The patient should be properly evaluated for presence of any pathological lesions in the oral cavity. All teeth having caries should be treated and restored. Elimination of all potential sites of infection must be the primary objective. Patient should be in a state of good oral and dental health during the active phase of bisphosphonate therapy so that invasive dental treatment would not be necessary. All extractions, dental implant placement, and other surgical procedures should be done before bisphosphonate therapy starts. A complete dental evaluation prior to bisphosphonate therapy includes the following:

A comprehensive extraoral and intraoral examination should be performed. A full mouth radiographic series and a panoramic radiograph will help in the diagnosis of caries and periodontal disease, the evaluation of third molars and the identification of metastatic cancer and other bony lesions.
The periodontal health status should be determined and appropriate therapy provided. Pocket elimination is of importance to reduce plaque accumulation, minimize chronic periodontal inflammation and minimize acute periodontal infections.
Necessary extractions should be completed and healing attained prior to bisphosphonate therapy.
Restorative dentistry should be performed to eliminate caries and defective restorations. Dentures should be evaluated for fit, stability and occlusion.
Prophylaxis should be performed and oral hygiene instructions given. The patient should be educated about bisphosphonates and osteonecrosis of the jaw (ONJ). Periodic oral examination and regular hygiene protocol should be scheduled to maintain healthy oral condition during the course of bisphosphonate therapy.

Treatment of established ONJ: The goals of therapy in those patients with established ONJ are to eliminate pain and infection and minimize the progression of necrosis. Most patients with limited areas limited areas of exposed bone that are asymptomatic can be managed with irrigation alone and close follow-up. Patients with symptomatic areas of exposed bone that are infected will require oral antibiotic rinses and oral antibiotic therapy for pain relief and infection control. Areas of necrotic bone that are constant source of soft tissue irritation should be removed without exposing additional bone. However, it is likely that the margin of the debridement will remain exposed. Symptomatic patients with large areas of infected necrotic bone or with pathologic mandibular fractures require surgical resection.

Discontinuation of IV bisphosphonates offers no short term benefit. However, if systemic conditions permit, long-term discontinuation may be beneficial in stabilizing established sites of ONJ, reducing the risk of new site development and reducing clinical symptoms.

Management of dental care for patients with osteonecrosis of the jaw (ONJ)

Following are recommendations for the management of the dental care of patients with osteonecrosis of the jaw (ONJ).

Routine restorative care may be provided. Local anesthetic can be used as necessary.
Scaling and prophylaxis should be done as atraumatically as possible, with gentle soft tissue management.
Avoid dental extractions, dental implant surgery, and other dental surgery if possible unless the teeth have a mobility score of 3 or greater. Extractions should be performed as atraumatically as possible. Patients should be followed up weekly for the first 4 weeks, then monthly, until the sockets are completely closed and healed. If there is an indication for antibiotic use, amoxicillin alone or in combination with clindamycin, may help to reduce the incidence of local infection.
Teeth that are extensively carious should be considered for endodontic therapy rather than extraction. If feasible, they should be prepared as overdenture abutments. The crown should be cut off at the gingival margin. This is particularly important in patients in whom a previous extraction had resulted in ONJ. In these patients, extraction should be avoided whenever possible.